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1 AUDITOR OF STATE WA S H I N G T O N NOV 11, 1889 Washington State Auditor s Office Troy Kelley Independence Respect Integrity Performance Audit Health Care Authority s Oversight of the Medicaid Managed Care Program April 14, 2014 We conducted this performance audit of the Health Care Authority s Medicaid managed care program to determine if the state had controls in place to effectively oversee the organizations in charge of providing health care and to prevent overpayments. We found weaknesses in HCA s oversight led to these organizations paying providers more than was appropriate, which in turn may have led to the state paying higher premiums to these organizations in fiscal year 2013 and beyond. We provide recommendations to help HCA improve its oversight of managed care organizations. Audit Number:

2 Table of Contents Executive Summary 3 Introduction 6 Background on Medicaid Managed Care 12 Audit Scope & Methodology 17 Audit Results 21 Recommendations 42 Agency Response 44 Appendix A 52 Appendix B: Methodology 53 Appendix C: Criteria 57 Appendix D: Best practices 68 Appendix E: Community Health Plan of 73 Washington (CHPW) additional testing results Appendix F: Molina additional testing results 77 Appendix G: Glossary 81 The State Auditor s Office contracted with Myers and Stauffer LC to conduct this audit. The mission of the Washington State Auditor s Office The State Auditor s Office holds state and local governments accountable for the use of public resources. The results of our work are widely distributed through a variety of reports, which are available on our Web site and through our free, electronic subscription service. We take our role as partners in accountability seriously. We provide training and technical assistance to governments and have an extensive quality assurance program. For more information about the State Auditor s Office, visit Americans with Disabilities In accordance with the Americans with Disabilities Act, this document will be made available in alternative formats. Please for more information. State Auditor s Office contacts State Auditor Troy Kelley , Chuck Pfeil, CPA :: Director of State & Performance Audit , Lou Adams, CPA :: Deputy Director of Performance Audit , Melissa Wade :: Senior Performance Auditor , Thomas Shapley :: Deputy Director of Communications , To request public records Mary Leider :: Public Records Officer , Medicaid Managed Care :: Executive Summary 2

3 Executive Summary Medicaid managed care is large and growing Washington s Medicaid managed care program, jointly funded by the federal and state government, provided health coverage for about 796,000 residents and cost almost $1.4 billion in The Health Care Authority (HCA) expects federal health care reforms starting in January 2014 will expand Medicaid coverage to about 328,000 more people in Washington in the next five years, most of whom are expected to receive managed care. We conducted this performance audit of the managed care program to determine if the state had controls in place to effectively oversee the organizations in charge of providing health care and to prevent overpayments. We found that weaknesses in HCA s oversight led to these organizations paying providers more than was appropriate, which in turn led to the state paying higher premiums to these organizations in fiscal year 2013 and beyond. AUDIT ISSUES Inadequate oversight and data analysis led to overpayments Undetected overpayments in 2010 resulted in potential higher premium costs in 2013 Data used to set 2013 premium rates was not verified and retained Inconsistent reporting of administrative costs, recoveries and rebates RECOMMENDATIONS Create a comprehensive monitoring and reporting system Review and improve the controls used to prevent overpayments Review and retain data used by the actuary to set premium rates Provide better guidance and require more reporting of key information Managed care organizations receive from the state monthly per-person payments. They use that money to pay doctors and other providers for client care. The system limits the state s exposure to increasing medical costs. However, the per-person rate the state pays is based in part on how much spending managed care organizations report. Because overpayments by the organizations inflate those figures, they put the state at risk of paying unnecessarily high premium rates in the future. The state s contracted managed care organizations annually process millions of claims for hundreds of thousands of members. Our objective was to determine whether overpayments occurred in an amount sufficient to warrant additional monitoring of claims. After evaluating similar work in other states and examining the reporting requirements in Washington, we focused our analysis on eight areas which pose the greatest risk for loss of public funds. Overpayment/Premium increase cycle WHY? Inadequate oversight and controls Managed care organizations overpay providers Cycle starts again in the new fiscal year unless improved oversight prevents overpayments Managed care organizations report higher expenses to actuary Actuary calculates premium to reflect higher spending State pays higher premiums to managed care organizations Medicaid Managed Care :: Executive Summary 3

4 This approach allowed us to limit the cost of the audit. Because we intentionally chose claims areas with the greatest risk of errors in only eight high-risk areas, we cannot use this approach to estimate the amount of overpayments in the entire system or to estimate amounts for potential recovery. Our approach did, however, provide us with evidence that additional monitoring of claims is warranted. Inadequate monitoring and insufficient controls led to inappropriate payments in 2010, which potentially affected 2013 premium rates We found inadequate oversight of the managed care program and limited controls over expenditures. For example, although the HCA s contract requires its managed care organizations to perform data checks to prevent improper payments, the organizations only had checks to analyze hospital claims and did not perform similar checks on professional claims by doctors and other specialists. Performing additional checks and data analysis, particularly for high risk claims, could help the state and its managed care organizations identify and reduce overpayments. Failure to resolve these issues will lead to higher Medicaid costs, especially as growth and enrollment in Medicaid managed care increase with federal health care reform. To determine whether overpayments to providers were detected, we examined eight of the highest-risk payment types at the two largest managed care organizations. Our best estimate is that the two managed care organizations overpaid their providers $17.5 million for claims paid within the eight outlier populations reviewed. These estimated overpayments in 2010 may have resulted in additional costs to the state, because the 2010 expenditures reported by managed care organizations were used to calculate the premium rates paid by the state to managed care organizations starting in To determine how overpayments may have impacted premium payments, we conducted an actuarial analysis that showed that for every $1 million in overpayments in 2010, the state potentially paid an additional $1.26 million in premiums in fiscal year However, because we don t know whether there were net overpayments in the entire system, we cannot estimate the impact on premium costs to the state. While the overpayments we estimated are a relatively small percentage of the $1 billion of payments the managed care organizations make to their providers annually, we made the estimate based solely on the limited testing of eight high-risk areas. The estimated impact on future premiums was based on a high-level analysis that applied the same assumptions and used the same limited amount of information disclosed in the actuary s rate setting memo. Access to more detailed information on the actuary s rate setting process might have yielded different results. The effect of these estimated overpayments on state premiums therefore warrants improved state oversight of the managed care program. Examples of inappropriate charges: Charging for a more complex medical evaluation than was performed. Extra charge for a medical evaluation when the evaluation is already included in the cost of a medical procedure. Charging for a hospital stay when there is no evidence the physician ordered inpatient admission. No documentation to support the services billed. Medicaid Managed Care :: Executive Summary 4

5 HCA did not review relevant managed care organizations cost data The state needs to ensure its managed care organizations correctly report administrative costs and cost recoveries, such as pharmacy rebates and recoveries received from other insurance companies. The HCA s current system does not capture, review or audit the actual administrative costs incurred by the state s managed care organizations, but relies on the organizations to report cost information directly to the HCA s actuary, without state oversight. High error rates (8 percent and 12 percent for the two organizations) of unallowable administrative expenses in the risk-based sample we reviewed suggest that the administrative costs reported to the actuary may be higher than their actual expenditures. In addition, the organizations also included some administrative costs in their medical costs, which is against program rules. The HCA s third-party actuary told us that it does not use the administrative cost data reported by the organizations to calculate the portion of the premium rate that applies to administrative expenses. Instead, the actuary uses national averages to set a rate of 13.5 percent of the premium to cover allowable administrative costs, premium tax and risk margin. It is a common practice among insurance actuaries to use national averages, which are not based on audited cost data, to compute premium rates. Does that mean errors in administrative costs do not matter? We believe that while use of national averages to set administrative expense rates may be common practice, the HCA would benefit from periodically analyzing actual administrative cost data reported by managed care organizations to ensure that it is accurate and reimbursement rates are reasonable. This would ensure that using national average administrative cost reimbursement rates is the right approach for Washington. Improving Medicaid managed care oversight Washington needs to collect more information about the performance of its independent contractors. It would benefit from a comprehensive cost reporting and monitoring system to keep managed care organizations accountable for the terms in the contract. An integral part of oversight is giving guidance to the managed care organizations. We found some circumstances in which the state did not provide proper guidance, and others in which the managed care organizations processes were not consistent or complete. Our recommendations for HCA include: ensuring the managed care organizations improve their controls to prevent overpayments establishing a comprehensive cost reporting and monitoring system providing better guidance and standards for reporting costs, recoveries and prescription rebates. The HCA should also seek to change the contract to allow it to recover a portion of any future overpayments identified and collected following state audits. The current contract is silent on whether or not the state can recover overpayments identified in state and other audits. Medicaid Managed Care :: Executive Summary 5

6 Introduction Medicaid managed care programs help those who need health care but can least afford it and the programs are likely to grow in coming years The public insurance program known as Medicaid is the single largest health care program in the United States. A partnership between federal and state government, it gives 67 million low-income Americans access to health care and related services. Those served include people with disabilities, children in low-income families, and low-income seniors who have Medicare. About 50 million of them are covered by some type of managed care program. Under a managed care program, the state pays an organization a monthly premium to manage all the healthcare services provided to plan participants. The remaining eligible individuals are covered under the more traditional fee-for-service type program. In a fee-for-service arrangement, the state reimburses providers for each specific service provided to plan participants. Beginning in 2014, the Patient Protection and Affordable Care Act will begin to expand Medicaid eligibility to cover an estimated 16 million more Americans mostly uninsured adults by About 1.2 million people almost 18 percent of Washington s population were enrolled in the state s Medicaid program in As shown in Exhibit 1, around 796,000 people 64 percent of members now receive medical care through managed care, with the remainder covered under a fee-for-service arrangement. The number covered under a managed care program will almost certainly go up because most new members added under the Affordable Care Act are likely to be directed to managed care programs. The Washington State Health Care Authority (HCA) estimates a total of 1.56 million people will be enrolled in all its Medicaid programs by Exhibit 1 - Medicaid managed care is growing In 2013, about 796,000 Washington Medicaid members received managed care Enrollment in millions The Affordable Care Act is implemented; enrollment estimates for 2014 are not currently available enrollment estimates for all Medicaid programs combined: 1.56 million Fee-forservice 47% 44% 43% 44% 36% Managed care* 53% 56% 57% 56% 64% Projected *Includes Healthy Options and other types of Medicaid managed care programs. Medicaid Managed Care :: Introduction 6

7 This increasingly popular care model allows the state to engage one or more managed care organizations to deliver services through their networks of providers: doctors, hospitals, clinics and so forth. Managed care organizations may be non-profit or for-profit businesses; some companies also operate clinics or provide community health programs, but their primary business is health insurance. The organizations contract with doctors, hospitals and other care providers to establish a network that provides health care services for the enrolled, eligible, plan participants. In Washington, the state pays the managed care organizations monthly premiums, allowing members to access covered services delivered by plan providers. The HCA hires an independent actuarial firm to determine these per-member monthly premium rates, based on data and costs reported by the managed care organizations. Periodically, the actuary revises the premium rate based on updated costs. An overstatement of costs can drive up the premium rate, which in turn drives up the amount the state spends in coming years for health care. HCA has focused its oversight on fee-for-service programs, and relies on managed care organizations to ensure costs reported to the actuary for rate setting are accurate. Its oversight of the managed care organizations is primarily focused on quality of care and not on the prevention and detection of improper payments within the managed care system. In fiscal year 2013, combined state and federal Medicaid spending in Washington totaled around $7.9 billion for medical and other support services. The amount spent on medical assistance in both the fee-for-service program and the managed care program was $4.6 billion. Federal funds from the Federal Medical Assistance Program paid about 54 percent of the total bill; Washington paid the remaining 46 percent, roughly $2.1 billion. Payments to the Medicaid managed care organizations from state and federal funds came to more than $1.4 billion. In conducting this audit, we engaged Myers and Stauffer LC to perform an analysis of the Medicaid managed care program Healthy Options, administered by the HCA. Myers and Stauffer is a nationally-based certified public accounting firm focused solely on providing accounting, consulting, program integrity and operational support services to public health care and social service agencies. We wanted to know if overpayments exist within managed care and how well the HCA did at monitoring the organizations costs, and preventing and detecting overpayments. This audit asked the following questions: 1. Are managed care organizations overpaying for medical expenses? If they are, why did overpayments go undetected, and how do the overpayments affect premium rates? 2. Are policies and procedures in place to ensure costs reported by managed care organizations to the third-party actuary: Offset recoveries, rebates and refunds against medical costs Include only allowable administrative expenses and allocate costs on a reasonable basis; and Report costs related to subcontractors properly? The audit focused on a few potentially high-risk areas To examine every possible source of overpayments would have required an audit many times larger than this one. To keep within a reasonable scope, we examined only a limited number of carefully selected areas where claims overpayments or other errors in reporting are most likely to appear. The results of our work must be looked at in that context: we did not estimate overpayments on non-outlier claims or other medical claim groups. Because problematic areas change over time, as gaps in practices are fixed, the issues we identified in this audit may not be the areas to reexamine five years from now. Instead, regular vigilance to prevent and detect overpayments, across the program, should become the HCA s routine practice. Medicaid Managed Care :: Introduction 7

8 Answer in brief Washington should improve its oversight of managed care organizations costs used to set premium rates. We selected for our study the two largest managed care organizations contracted by the HCA to provide Medicaid managed care in the Healthy Options program; together they cover about 80 percent of the program s members and represent about $1 billion a year in Medicaid spending. We found that, in general, the organizations follow the requirements of their contracts with the HCA. However, we also found errors resulting in overpayments to providers within the high-risk claims areas we examined in detail. These overpayments were the result of incomplete systems checks and review processes conducted by the managed care organizations that should be designed to catch overpayment possibilities. Overpayments also occurred because the HCA does not have a comprehensive system to monitor the review procedures performed or the costs incurred by the managed care organizations. Neither HCA nor other Washington state audit entities have conducted a detailed review of the kind undertaken in this audit. Overpayments for managed care services can result in higher costs to the state Our limited, risk-based review of transactions identified $96,860 in overpayments and one significant underpayment of $21,169. After projecting these results using statistical analysis, our best estimate is that the two managed care organizations overpaid their providers $17.5 million for claims paid within the eight outlier populations reviewed. Our approach was designed to identify only potential overpayments and our results do not include overpayments and underpayments that may have been found in a random test of the entire population. We therefore don t know whether there were net overpayments in the entire system. Overpayments are a cost to the managed care organizations, but they also potentially affect the future premium rates paid by the state. Premium rates starting in fiscal 2013 were based on costs reported by managed care organizations in 2010, the year we reviewed. Net overpayments in the entire Medicaid managed care system lead to increased premium payments by the state. Based on an estimated 695,000 medicaid managed care members, if there are net overpayments, we estimate that for every $1 million paid by organizations to their providers in 2010, the state would pay an additional $1.26 million in premiums to all managed care organizations. However, because we don t know whether there were net overpayments in the entire system, we cannot conclude that 2013 premiums paid by the state were higher or lower than they should have been. We estimated the impact on future premiums using a high-level analysis that applied the same assumptions and used the same limited amount of information disclosed in the actuary s rate setting memo. Access to more detailed information on the actuary s rate setting process might have yielded different results. Additional premiums paid in one year will compound due to increased enrollment as long as premium rates are based on inflated costs. The potential effect of overpayments to providers on state costs warrants increased monitoring. Medicaid Managed Care :: Introduction 8

9 Washington could also contain Medicaid costs by reviewing medical cost recoveries and administrative expenses When we examined administrative expenses and recoveries, such as pharmacy rebates and overpayment recoveries, in the financial reports sent to the actuary, we found that organizations generally reduced the medical claim costs by the amount of recoveries or rebates received. However, we found some errors that overstated the medical expenses the organizations reported to the actuary. We found third-party recoveries totaling $1.1 million were not used to offset the cost of related medical claims, resulting in overstated medical expenses reported to the actuary. We found unallowable administrative expenses totaling $395,000 were reported to the actuary, representing an error rate of 8 percent and 12 percent for the two managed care organizations in our sample. We could not determine how the HCA s third-party actuary used cost information related to capitated providers in calculating the premium rate. The actuary had received two sets of costs from one of the organizations: projected costs based on fee-for-service rates and actual costs based on capitated payments paid to their providers. Capitated payments were $3.3 million less than the projected costs. The actuary could not give us documentation showing how they considered the two sets of costs when calculating the rate, and did not maintain information that was used in the calculation of the capitation rate in an accessible format. The actuary does not review administrative costs for accuracy or improper payments when calculating the portion of the premium rate that applies to administrative expenses. To assure the state that the rate being applied to Washington is appropriate, the administrative expenses applied to the administrative cost percentage rate should be reviewed and verified. Washington should require managed care organizations to retain and report complete accurate cost data reported for rate setting purposes In addition, we found that the HCA s contract with the managed care organizations does not contain requirements that would allow the HCA to thoroughly and accurately monitor the data they report to the actuary. Although the organizations we audited provide financial reports to the HCA s third-party actuary that contain cost data from the previous year, neither kept the detailed medical claims cost data as it was submitted to the actuary. In order to receive federal Medicaid funds, Washington must meet numerous requirements regarding the proper and efficient administration of their Medicaid programs, including its use of managed care. By not requiring the organizations to report cost data to HCA and retain the data files for review, the HCA is not in a position to adequately monitor the costs the organizations have incurred and reported to the actuary. Medicaid Managed Care :: Introduction 9

10 HCA should strengthen the guidance it provides to its contracted managed care organizations We found several instances in which clearer guidance from the HCA could improve the way the managed care organizations compute and report data to the actuary. For example, we found that the two organizations in our study calculated and reported their pharmacy rebates differently one on an accrual basis, one on a cash basis making it difficult to compare their results and performance accurately. Nationally, as more states expand the number of members served by managed care organizations, there is a move towards more accountability and transparency regarding the Medicaid dollars these companies are paid. The Centers for Medicare and Medicaid Services (CMS) and the U.S. Senate Judiciary Committee addressed these issues through a request to the State Medicaid Directors, and proposed legislation that would require annual audits of these programs. At the state level, some states, such as Georgia and Texas, have already established comprehensive monitoring programs; some require audits conducted by independent auditors. If Washington is to keep pace with managed care s increasing role in Medicaid and fulfill its obligation to administer the program effectively, it must improve the way it monitors managed care organizations and holds them accountable. See Appendix D for monitoring best practices and the states that use them. Summary of recommendations The Health Care Authority should improve its oversight of managed care organizations to ensure appropriate controls are in place to detect and prevent medical and administrative cost overpayments, and also provide guidance on the reporting of medical cost recoveries and administrative costs. By examining and updating its contract language with the managed care organizations as appropriate, the HCA should be able to address our recommendations and allow the state to recover any future overpayments identified in state and other audits. Our recommendations include these key elements: 1. Review and improve the controls used to prevent overpayments by requiring the managed care organizations to review their system edit checks and post-payment procedures to ensure claims are reviewed in sufficient detail to identify miscoding and other causes of overpayments. The contract should require that organizations use edits such as those established by the National Correct Coding Initiative (NCCI). 2. Update contract language with the managed care organizations to allow the HCA to recover overpayments identified in state and other audits where appropriate. 3. Require the organizations to report detailed claims and administrative cost data to the HCA in a prescribed format on a periodic basis. 4. Create and implement a comprehensive revenue, cost reporting and monitoring system to enhance accountability for the managed care organizations compliance with contract provisions. 5. Provide better guidance and criteria for defining medical and administrative expenses and recoveries, including what are allowable expenses and when rebates and recoveries should be reported. For our full recommendations, please see pages 42 and 43. Medicaid Managed Care :: Introduction 10

11 What s next We conducted this performance audit under the authority of the state s performance audit law which was enacted in 2005 through the statewide citizen initiative I-900. The law requires the responsible legislative body to hold a public hearing within 30 days of its publication. Representatives of the State Auditor s Office will report on this performance audit to the Joint Legislative Audit and Review Committee or another legislative committee. Please check the state Legislature s website (www.leg.wa.gov) for the exact date, time, and location. The public will have the opportunity to comment at this meeting. Appendix A describes the provisions of Initiative 900 and how the audit addressed these provisions. Appendix B provides more detail on our objectives and methodology. Medicaid Managed Care :: Introduction 11

12 Background on Medicaid Managed Care Medicaid managed care programs provide greater control and predictability over Medicaid spending The goals of a managed care program are to improve care, reduce costs, expand service delivery options, reduce inappropriate utilization, and assure adequate access to quality health care for Medicaid beneficiaries. Such programs deliver covered health benefits and additional services through a risk-based contract between the state Medicaid agency and a managed care organization; states usually contract with more than one organization to provide services statewide. Under a risk-based contract, the managed care organization assumes a portion of the short-term financial risk for the cost of covered services and plan administration. It negotiates with providers to create a network that will provide services to plan members at specified rates. In return, the state pays the organization a fixed periodic (usually monthly) payment for a defined package of benefits. These payments are commonly known as premiums or capitation payments; they are typically made on a per-member, per-month basis. This structure is designed to provide the state with greater control and predictability over Medicaid spending. In determining premium rates, third-party actuaries predict members use of health care services and the expected cost of these services based on a number of factors, such as: Baseline cost of claims data Expected trends State fiscal conditions Services that are not covered by managed care Payments in addition to the base premium rate Incentives Federal regulations require a state s premium rates to be actuarially sound and certified by a qualified actuary. Rates are actuarially sound if they provide for all reasonable, appropriate, and attainable costs that are incurred by the managed care organizations. However, this determination by the actuary does not include reviewing the costs for overpayments or allowability under the Medicaid program. Since the rates paid to the organizations are based in part on the actual cost of medical and administrative services they have paid for, it is essential that states have an effective oversight program in place to ensure only reasonable and allowable costs are factored into the actuary s rate setting equation. Federal laws and guidance (see page 59) also set out what states should regard as errors and overpayments, which are defined as: Payments made to ineligible recipients Payments for services that are not covered by the member s plan Payments for services that the member did not receive Payments for incorrect amounts Duplicate payments Payments where an audit or review by the state agency cannot determine if the payment was correct because of insufficient or absent documentation Medicaid Managed Care :: Background 12

13 In addition, in order to receive federal Medicaid funds, Washington must meet numerous requirements regarding the proper and efficient administration of its Medicaid programs. Given the magnitude of these programs, Washington has a statutory obligation to know whether or not it is paying appropriately for quality care and whether members have adequate access to necessary care. Robust program integrity efforts by managed care organizations, combined with accountability efforts by the state in managing their managed care organization contracts help to control Medicaid costs. As an integral component of program accountability, program integrity efforts seek to ensure proper payment for appropriate, high quality health care services. This includes addressing not only fraud, waste, and abuse by providers and plan members, but also program management issues. Program accountability measures also extend to the managed care organizations. In Washington, the organizations Healthy Options contract with the state requires them to follow all applicable federal and state program integrity requirements. Under prudent contract management practices, the state must monitor the organizations program integrity efforts. Indeed, the organizations have their own incentives to identify and address possible fraud, waste and abuse because they are paid a set rate for each person enrolled in their plan. Any undetected fraud, waste and abuse in managed care that results in overpayment of medical and administrative costs means the organization would bear the short term responsibility to cover that cost. A robust process for monitoring and detecting overpayments of claims and other expenses though in itself an administrative cost can go a long way toward preventing and detecting problem expenditures. It is important for all states to actively monitor and manage their Medicaid managed care contractors because without robust processes in place, overpayments of medical and administrative costs are more likely to occur and not be caught. Over the long term, these overpayments will increase future premium rates, which means the managed care organizations will eventually recover their short-term losses. The burden thus falls on the state through higher premium rates. It is in the state s interest to limit cost increases today if it wishes to reduce the overall cost of its Medicaid managed care program tomorrow. Increased monitoring on the part of HCA can provide the oversight and effective management needed to achieve cost savings. Without adequate oversight, states risk paying Medicaid managed care premium rates that are too high Three factors drive managed care premium rates set by the HCA s third-party actuary: Medical expenses (how much did each medical service in a claim cost) Claims experience (how many encounters with the medical community did members have in a year) Administrative costs (how much does it cost an organization to run its business) Generally, overpayments in managed care programs can be the result of the following: Overpaying medical costs through miscoding of medical claims, use of improper reimbursement rates to providers, or lack of documentation to support a claim. Failure to offset rebates and recoveries against medical costs. Overpaying administrative costs through inflated fees for related party cost. Inaccurate reporting of encounter data. Misallocating non-medicaid costs to the Medicaid program. Misallocating corporate overhead expenses to the Medicaid program. Charging unallowable costs to the program such as specified costs that don t qualify for federal reimbursement under regulations Unknown costs and excessive fees for delegated vendors or related parties. Medicaid Managed Care :: Background 13

14 Question 1 of this report addresses the claims payments that make up the medical expenses. If a managed care organization overpays on medical claims and reports uncorrected data to the actuary, premium rates are likely to be set higher to reflect the high expenditures. Question 2 examines how managed care organizations report the recovery of medical expenses from third parties like insurance companies, and manage their administrative costs. If the organization recovers money but doesn t report it to the actuary, the higher original expense is used to calculate the premium rate; if it inappropriately includes certain administrative costs as medical costs or includes unallowable administrative costs, total expenses would be overstated and again, the premium rate would be incorrectly calculated. Preventing the risk of fraud, waste and abuse is often discussed in terms of efficient and effective operation of state Medicaid programs and prudent fiscal management of Medicaid funding. However, states might underestimate the risks to their Medicaid budgets under the premium payment structure because, in some instances, they have limited their short-term cost exposure to the premium payment made to the managed care organizations. States might also assume that the managed care organizations address these risks as part of their program integrity function, or the state s actuary firm monitors them as it calculates the premium rates for the program. In reality, none of these entities necessarily address these risks without specific contractual requirements imposed by the state. While the state contracts with various managed care organizations to operate the Medicaid managed care program, it is still responsible for making sure that they comply with all aspects of the contract. Among the most important elements that best practices recommend a contract include are requirements that: The costs to operate the program are allowable and reported accurately Premium payments are based on accurate member eligibility counts Adequate physician and medical facility networks are established Medical services are provided promptly and properly Personal health information is protected adequately Claims are paid properly and on time to the providers Careful terms set out in the contracts between the state and its managed care organizations can encourage improved, more comprehensive oversight, and help keep costs down. Medicaid Managed Care :: Background 14

15 Four key risks states can mitigate by monitoring costs and operations at managed care organizations Four important risks can be mitigated if the state establishes a comprehensive monitoring program that ensures oversight of the costs incurred to operate the Medicaid program under managed care. These risks and their remedies are: 1. Premium rates set higher than they should be By checking that providers have not been overpaid, expenditures have been accurately offset with recoveries, and administrative costs are properly allowable, program management can ensure that rates are not set higher than is appropriate. 2. Misstated medical loss ratio calculations State contracts generally require managed care organizations to comply with a certain medical loss ratio target, which ensures that the organization spends a minimum percentage of premium revenues on medical services for members, restricting the amount spent to operate the program. The usual ratio is 80 percent to 85 percent on medical expenses; Washington s required medical loss ratio is 80 percent. By reviewing cost allocations, agency management can ensure that this ratio is correctly calculated. Inaccurate medical loss ratio calculations can disguise a lack of access to care for members and conversely over-spending on administrative costs. Managed care organizations that do not comply with the required ratio may incur a penalty which could create an incentive to report inflated medical expenses. 3. Paying for duplicate or ineligible plan members By regularly reviewing member files for accuracy, management can find and remove doublecounted members or people enrolled who are not eligible to receive Medicaid benefits. 4. Problems arising from non-compliance with contract performance requirements State contracts generally contain provisions that require the organizations meet specified performance standards. By monitoring compliance with these contract provisions, management can ensure adequate medical coverage for Medicaid plan members, good customer service, and reduce the chances of Health Information and Portability Accountability Act (HIPAA) violations. Typical contract requirements include: Adequate network coverage Adequate access to provision of care Accurate provider directories that reflect actual experience Timely and adequate call center operations Member and provider satisfaction Adequate information technology (IT) security systems to protect personal health information Timely and comprehensive claims processing complaint handling Medicaid Managed Care :: Background 15

16 Background information specific to Washington s Medicaid Managed Care program Since July 2011, the HCA has administered Medicaid and state-only funded managed care contracts in Washington, including Healthy Options. Our audit work focused on Healthy Options, the largest state managed care program, which provides no-cost health care services for people receiving Medicaid. During the one-year period of our audit January 1 through December 31, 2010 the Medicaid Healthy Options program was administered by the Department of Social and Health Services (DSHS). The agency was also responsible for determining Medicaid eligibility for members and maintaining the Automated Client Eligibility System that processes Medicaid eligibility. This system, updated daily, interacts with HCA s Medicaid Management Information System (MMIS) called ProviderOne. The ProviderOne system: Contains rules regarding a client s eligibility for managed care enrollment Processes member enrollment in managed care Processes payments to managed care organizations. In 2010, the state had contracted with seven managed care organizations to provide services: Community Health Plan of Washington (CHPW) Molina Healthcare of Washington, Inc. (Molina) Asuris Northwest Health Columbia United Providers Group Health Cooperative Kaiser Foundation Health Plan Regence BlueShield Changes in 2012 reduced the number of contracts The number of contracted managed care organizations was reduced to five in 2012, with only two of the original seven continuing to provide services under new contracts. As of July 1, 2012, the HCA entered into 18-month contracts with the five managed care organizations: Amerigroup, Coordinated Care Corp, and United Healthcare Community Plan, as well as CHPW and Molina. The contract covered provision of health care services to members of Healthy Options and the state s Basic Health Plan, a subsidy program for low income residents not eligible for Medicaid. Medicaid Managed Care :: Background 16

17 Audit Scope & Methodology The state s contracted managed care organizations annually process millions of claims for hundreds of thousands of members. Because the first objective of this audit was to determine whether overpayments occurred, and not to estimate amounts for potential reimbursement, we were able to limit the number of transactions tested while still meeting a 90 percent confidence interval for statistical estimates. The risk-based approach we applied does have its limitations, however. Because we selected our samples from selected groups of claims with potentially high risk of overpayments, we cannot use this approach to estimate the amount of overpayments or underpayments in the entire population of claims incurred in Nonetheless, this analysis provides evidence of the magnitude of potential overpayments information that is useful to determine whether additional monitoring of claims is warranted. Appendix B contains more details about our methodology and sampling. Analysis conducted to identify overpayments We analyzed calendar year 2010 claims because these were used by the thirdparty actuary to determine reimbursement rates starting in fiscal year Our risk-based approach was performed as follows. We included the two largest managed care organizations (Molina and CHPW) in our analyses. These two organizations cover more than 80 percent of Healthy Options enrollees and received about $1 billion in premium payments in calendar year We identified 31 medical claim groups that had significant potential risk of overpayment based on a risk assessment that included a review of laws, regulations, contracts and data analysis, as well as the contractor s prior experience and expertise, including familiarity with other state programs. We identified claims that were outliers. These are claims that appear to be different in volume, value, nature or timing from others in a group of similar claims. The 31 high-risk groups accounted for $130 million of outlier claims in We narrowed the number of groups in our analysis to eight, based on the potential for amounts overpaid in outlier claims and the ability to identify overpayments in the medical records. These eight groups, described in the table on the following page, accounted for $90 million of outlier claims in We then determined the sample size needed to have a confidence interval of 90 percent for each of the eight high-risk areas. We randomly selected 575 claims for testing, amounting to $2.4 million. We conducted an expert review based on an examination of the medical files on 575 randomly-selected claims. Our initial testing of the medical claims was based on what was documented in the medical files received from the managed care organizations. For pharmacy claims, we also reviewed prior authorizations and related policies and procedures. The two organizations were given the opportunity to provide additional support for any initial exceptions identified before final errors were determined. The claims we identified as errors in our sample were not paid in compliance with standard medical coding practices or were not properly supported with appropriate documentation. Medicaid Managed Care :: Audit Scope & Methodology 17

18 The eight high-risk claims groups we examined in this audit What the claims group does or includes Upcoding diagnosis-related group (DRG) codes. Medical billing systems offer several diagnosis-related group (DRG) codes, which ascend numerically as the amount of effort required of the provider increases. High numbered DRG codes pay at a higher rate. They are applied for the greater levels of service performed for inpatient procedures in hospitals. Unbundling CT (computerized tomography) scans. Certain related services are bundled into a single payment to the provider. If a claim is submitted for a service that must be bundled with an additional code for one of the procedures included in the bundle, the payment for the additional code should be denied. Some of the CT scan procedure codes are bundled with other related services, generally where a CT scan would be a normal procedure in order to diagnose the illness or injury. One-day inpatient stay. For the same service, inpatient (admitted) hospital reimbursement rates are typically higher than outpatient (not admitted) rates. Excessive billing using Modifier 25 code. Providers apply a Modifier 25 code to indicate that on the day of a procedure, the patient s condition required a significant, separately identifiable evaluation and management service, above and beyond the usual pre- and post-operative care associated with the procedure or service performed. Under normal circumstances, we would expect to see the use of the Modifier 25 code only in exceptional circumstances. Duplicate payment of evaluation & management (E&M) codes. These codes are often included within other procedure codes. Many surgical procedure codes build in a component that includes an evaluation & management activity that is performed within one, ten or 90 days of the procedure date. Upcoding evaluation & management (E&M) codes. Medical billing systems offer several evaluation and management codes, which ascend numerically as the amount of effort required of the provider increases. A higher numbered E&M code pays at a higher rate. Recurring orders for controlled substance drugs. Controlled substance medications (identified in schedules II, III, and IV) have an increased potential for abuse; they include drugs such as methadone, OxyContin, anabolic steroids, codeine, Valium, and Xanax. They are typically prescribed for short-term use only. Recurring orders for atypical antipsychotic drugs. Similar to controlled substances, certain atypical antipsychotics drugs have an increased potential for abuse. Drugs in this class include Abilify, Seroquel and Zyprexa. Potential overpayment issues in this group A provider who frequently applies higher numbered DRG codes could be a specialist, but it is also possible the provider is misusing the codes to get a greater reimbursement rate. It may also indicate incorrect usage of these codes. The potential for overcharging may occur when providers bill additional, separate CT scan codes with the bundled procedures without the proper documentation to support the additional payment. Additionally, services may be charged separately instead of bundled resulting in higher overall charges. The potential for overcharging may occur when a provider admits the patient into a hospital when it was not medically necessary and treatment could have been provided on an outpatient basis, or when outpatient procedures are incorrectly billed as inpatient procedures. An unusually high percentage of billing under the Modifier 25 code might indicate potential duplicate payment, coding errors, or the intention of bypassing certain review controls. Since applying the Modifier 25 code gains the provider a higher rate for the services performed for that patient, the incentive to misuse Modifier 25 coding can result in overpayment of these claims. The potential for overcharging may occur when providers bill additional, separate E&M codes with these procedures without the proper documentation to support the additional payment. The use of codes with an embedded E&M code may indicate that the separately billed E&M did not occur or was not necessary. Providers with a high percentage of using the higher level E&M codes could indicate the provider is a specialist or that the provider is misusing the codes to get a higher reimbursement rate. The potential for overcharging may occur when a provider uses a higher level E&M code when it was not medically necessary and the documentation does not support the additional effort reflected by the higher code. Recurring orders for multiple months may indicate patients with addiction problems seeking excessive quantities of drugs or illegal selling schemes run by the patient or the provider writing the prescriptions, as many of these drugs have a high street value. Recurring orders for multiple months may indicate patients with addiction problems seeking excessive quantities of drugs or illegal selling schemes run by the patient or the provider writing the prescriptions, as many of these drugs have a high street value. Medicaid Managed Care :: Audit Scope & Methodology 18

19 We projected the results of our analysis to all outliers in the eight high-risk groups. Because we selected claims to test based on risk, this extrapolation was only performed on the limited population of outliers in the eight high-risk groups. We did not estimate overpayments on non-outlier claims or other medical claim groups. We then estimated the effects of potential overpayments on premium rates paid to the managed care organizations. Fiscal year 2013 was the first year in which reimbursement rates to the organizations were determined based on 2010 claims. We were able to estimate the additional premiums paid to all managed care organizations in fiscal year 2013 based on the effect of the estimated overpayments on per-member rates, assuming average enrollment of 695,000 people in the Healthy Options program. Thus, while the organizations absorb these medical costs in the year they occur, overpayments directly increase premium rates because they are included in the expense data reported to the actuary. The state budget is affected by these overpayments through the higher premium rates paid to the organizations in subsequent years. Exhibit 3 on page 24 illustrates the process we used in auditing claims. The benefits of a risk-based approach Our risk-based approach testing only a small fraction of the claims from two managed care organizations enabled us to determine whether overpayments were being made and the estimated effects on premium rates paid to the managed care organizations. While the limited number of claims gave us an estimate of overpayments that meets a 90 percent confidence interval, the estimate is less precise than it would have been with a larger sample size. To assure full disclosure, we will provide a not less than estimate of overpayments as well as the point estimate itself. Examining other costs In the second part of our audit, we reviewed a selection of other 2010 financial transactions at the two managed care organizations that, if incorrectly reported, could affect the premium rate calculation. The items we examined that present a risk of overstated costs included: Overpayment recoveries payments received from providers for overpaid claims. They should be applied against the claim to reduce costs. Third party recoveries payments from other responsible parties, such as group health plans, liability insurer settlements, or worker s compensation coverage. They should be applied against the claim to reduce costs. Reinsurance recoveries payments from the organization s insurance coverage for unforeseen or extraordinary losses exceeding a certain amount. They should be reported in the cost data as an offset to corresponding medical expenses. Pharmacy rebates payments from drug manufacturers for prescriptions filled for Medicaid patients. They should be reported in the cost data as an offset to medical expenses. Administrative expenses expenses incurred by the managed care organizations to administer their services. They should be permitted by law, correctly categorized, and correctly allocated to the Washington Medicaid program. Medicaid Managed Care :: Audit Scope & Methodology 19

20 Related party costs payments to affiliated management companies or providers. They should not include a profit component or be higher than the rate paid to unrelated providers for similar services. Subcontractor costs payments made by the managed care organizations to their subcontractors who provide administrative services to the organizations or medical services directly to Medicaid clients. The organizations should properly allocate and categorize administrative and medical costs for services provided by these subcontractors to comply with contract provisions. Payments to subcapitated providers regular monthly payments made by the managed care organizations to providers who render medical services to Medicaid clients. The actuary should provide the HCA with information used to calculate the capitation rate including how subcapitation payments and related fee-for-service equivalents were taken into account in the rate setting process. This would improve the transparency of the process and help the state monitor the development of the premium rates being paid to the managed care organizations to insure these special pricing arrangements are properly considered in the rate setting process. During the audit, we also interviewed staff and managers at the Health Care Authority, the two managed care organizations, and the third-party actuary. We conducted this performance audit under the authority of state law (RCW ), approved as Initiative 900 by Washington voters in 2005, and in accordance with Generally Accepted Government Auditing standards (December 2011 revision) issued by the U.S Government Accountability Office. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Appendix B provides more detail on our objectives and methodology. Subcapitation Just as the managed care organizations are paid per-member, per-month premiums by HCA for Medicaid services, so the managed care organizations can arrange to pay the care providers they have contracted with in the same way. Generally, these arrangements, known as subcapitation agreements, allow the organizations to pay less for claims expenses than they would pay under the fee-for-service model. Medicaid Managed Care :: Audit Scope & Methodology 20

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